Rating the Efficacy of Diagnostic Imaging Studies Conducted for the Workup of Musculoskeletal Tumors.

Background: Concerns for missed diagnoses have led to increased ordering of diagnostic imaging. Patients with suspected musculoskeletal tumors may undergo nondiagnostic and unnecessary imaging studies before referral to a musculoskeletal oncologist. This can result in patients receiving excessive radiation exposures, accruing unnecessary costs, delays in treatment, and an unnecessary burden on healthcare systems.

Purpose: The purposes of this study were to (1) internally rate the usefulness of imaging tests completed for musculoskeletal oncology patients undergoing evaluation using a novel scoring system, (2) determine the inter-rater reliability of providers who rated imaging tests, and (3) assess the costs incurred for imaging studies based on Medicare reimbursement rates.

Methods: A single-center, retrospective study was conducted on 112 patients who presented to our musculoskeletal oncology clinic for workup of a suspected mass from February 2021 to May 2021. After obtaining institutional review board approval, information regarding all radiographic images pertinent to the patient's workup was collected through a manual chart review. Patient information and images were sent to six fellowship-trained physicians for review. Providers then graded the appropriateness of each study using a five-point rating system. Final diagnoses were divided into three categories: bone lesions, soft-tissue lesions, and metastatic skeletal lesions. Inter-rater reliability was assessed using interclass correlation coefficient tests. The cost of wasteful tests was calculated using Medicare reimbursement rates.

Results: Three hundred twenty-two imaging studies conducted on 112 patients were included in the study. For primary bone lesions, plain radiographs and MRI scans with and without contrast were the highest rated diagnostic studies. For soft-tissue lesions, MRI and CT scans without contrast were the highest rated diagnostic studies. For metastatic bone lesions, positron emission tomography/CT and MRI scans with and without contrast were highly rated diagnostic studies. For all tumor types, core needle biopsy was the highest rated invasive study. The overall interclass correlation coefficient between all providers was 0.33. 1.2% of studies ordered by our department were considered wasteful, accounting for around $1,775 (2.3%) of costs.

Conclusion: Our study was conducted to internally rate the usefulness of imaging tests ordered for patients who presented to a musculoskeletal oncology clinic. For all tumor types, MRI, CT, and plain radiographs were frequently rated as helpful studies. Core needle biopsy was the highest rated invasive study. Bone scans were considered of limited utility for most bone lesions. The quantity of wasteful studies was low overall. Our study demonstrates the complexity in obtaining appropriate diagnostic imaging for the evaluation of musculoskeletal tumors.